<!--
  ========================LICENSE_START=================================
  screenit-web
  %%
  Copyright (C) 2012 - 2020 Facilitaire Samenwerking Bevolkingsonderzoek
  %%
  This program is free software: you can redistribute it and/or modify
  it under the terms of the GNU Affero General Public License as published by
  the Free Software Foundation, either version 3 of the License, or
  (at your option) any later version.
  
  This program is distributed in the hope that it will be useful,
  but WITHOUT ANY WARRANTY; without even the implied warranty of
  MERCHANTABILITY or FITNESS FOR A PARTICULAR PURPOSE.  See the
  GNU General Public License for more details.
  
  You should have received a copy of the GNU Affero General Public License
  along with this program.  If not, see <http://www.gnu.org/licenses/>.
  =========================LICENSE_END==================================
  -->
<html xmlns:wicket="http://wicket.apache.org">
<wicket:panel>
    <form wicket:id="form" class="not-tracked-for-changes-on-page">
        <div class="modal-header">
            <button type="button" class="close" data-dismiss="modal">&times;</button>
            <h3>Indexeren</h3>
        </div>
        <div class="modal-body row-fluid form-horizontal">
            <div class="span12">
                <div class="control-group">
                    <label class="control-label">
                        <wicket:message key="CervixTariefType.LAB_HPV_ANALYSE_UITSTRIJKJE"></wicket:message>
                    </label>

                    <div class="controls">
                        <input type="text" class="not-tracked-for-changes-on-page input-small" wicket:id="hpvAnalyseUitstrijkjeTarief"/>
                        <i class="icon-asterisk icon-purple"></i>
                    </div>
                </div>

                <div class="control-group">
                    <label class="control-label">
                        <wicket:message key="CervixTariefType.LAB_HPV_ANALYSE_ZAS"></wicket:message>
                    </label>

                    <div class="controls">
                        <input type="text" class="not-tracked-for-changes-on-page input-small" wicket:id="hpvAnalyseZasTarief"/>
                        <i class="icon-asterisk icon-purple"></i>
                    </div>
                </div>
                <div class="control-group">
                    <label class="control-label">
                        <wicket:message key="CervixTariefType.LAB_CYTOLOGIE_NA_HPV_UITSTRIJKJE"></wicket:message>
                    </label>

                    <div class="controls">
                        <input type="text" class="not-tracked-for-changes-on-page input-small"
                               wicket:id="cytologieNaHpvUitstrijkjeTarief"/>
                        <i class="icon-asterisk icon-purple"></i>
                    </div>
                </div>
                <div class="control-group">
                    <label class="control-label">
                        <wicket:message key="CervixTariefType.LAB_CYTOLOGIE_NA_HPV_ZAS"></wicket:message>
                    </label>

                    <div class="controls">
                        <input type="text" class="not-tracked-for-changes-on-page input-small" wicket:id="cytologieNaHpvZasTarief"/>
                        <i class="icon-asterisk icon-purple"></i>
                    </div>
                </div>
                <div class="control-group">
                    <label class="control-label">
                        <wicket:message key="CervixTariefType.LAB_CYTOLOGIE_VERVOLGUITSTRIJKJE"></wicket:message>
                    </label>

                    <div class="controls">
                        <input type="text" class="not-tracked-for-changes-on-page input-small"
                               wicket:id="cytologieVervolguitstrijkjeTarief"/>
                        <i class="icon-asterisk icon-purple"></i>
                    </div>
                </div>

                <div class="control-group">
                    <label class="control-label">
                        Geldig van
                    </label>

                    <div class="controls">
                        <div class="input-append date">
                            <input wicket:id="geldigVanafDatum" type="text"
                                   placeholder="dd-mm-jaar" size="16"
                                   class="input-small three-months not-tracked-for-changes-on-page">
                            <a href="javascript:void(0);" class="btn"
                               onclick="$(this).prev().datepicker('show');return false;" title="Datum"><i
                                    class="icon-calendar"></i></a>
                            <i class="icon-asterisk icon-purple" style="vertical-align: middle; margin-left: 3px;"></i>
                        </div>
                    </div>
                </div>
                <div class="control-group">
                    <label class="control-label">
                        Geldig t/m
                    </label>

                    <div class="controls">
                        <div class="input-append date">
                            <input wicket:id="geldigTotenmetDatum" type="text"
                                   placeholder="dd-mm-jaar" size="16"
                                   class="input-small three-months not-tracked-for-changes-on-page"/>
                            <a href="javascript:void(0);" class="btn"
                               onclick="$(this).prev().datepicker('show');return false;" title="Datum"><i
                                    class="icon-calendar"></i></a>
                        </div>
                    </div>
                </div>
            </div>
        </div>
        <div class="modal-footer">
            <a class="btn" data-dismiss="modal">Annuleren</a>
            <a href="javascript:void(0);" class="btn btn-primary" wicket:id="opslaan">Opslaan</a>
        </div>
    </form>
</wicket:panel>
</html>
